RSI Airway Assessment

New Hampshire
Division of Fire Standards & Training and
Emergency Medical Services
Introduction Slide
Purpose of this Module
 Review Airway Anatomy
 Learn Advanced Airway Assessment
Techniques
 3-3-2
 Laryngoscope View Grading
 Mallampati Classifications
 BURP
 IF
Endotracheal Intubation fails,
you must have a back-up plan...
Upper Airway
Upper Airway
Middle Airway
Thyroid versus Cricothyroid Cartilage
 Thyroid cartilage used
in “BURP” maneuver.
Does not form a
complete ring around
the trachea.
 Cricothyroid Cartilage
used in
CricoidPressure, does
form a full ring around
the trachea allowing
for the compression of
the esophagus.
Lower Airway
1. Preparation
 A two-part process:
 Assess the risks

 Prepare the equipment

Assess the Risks
Difficult Airways - Assess the Risks
“The difficult airway is something one
anticipates; the failed airway is something
one experiences.”

-Walls 2002
How do you know if your
patient is going to be difficult
to intubate…
…and does it really matter?
Some Predictors of a Difficult Airway
 C-spine immobilized  Dentures
trauma patient  Limited jaw opening
 Protruding tongue  Limited cervical
 Short, thick neck mobility
 Prominent upper  Upper airway
incisors conditions
(“buckteeth”)  Face, neck, or oral
 Receding mandible trauma
 High, arched palate  Laryngeal trauma
 Beard or facial hair  Airway edema or
obstruction
 Morbidly obese
Additional Predictors:
Medical History
 Joint disease  Previous problems
 Acromegaly in surgery
 Thyroid or major neck  Diabetes
surgeries  Pregnancy
 Tumors, known  Obesity
abnormal structures
 Pain issues
 Genetic anomalies
 Epiglottitis
Assess the Risk
 Identifying a
potentially difficult
airway is essential
to preparing and
developing a
strategy for
successful ETI and
also preparing an
alternate plan in
the event of a
failed ETI.
Objectives
 Identify 4 areas of airway difficulty
 Predict a difficult airway using the
following mnemonics:
 MOANS
 LEMONS
 DOA
Airway Difficulties
 Difficult to ventilate with a BVM
 Difficult laryngoscopy
 Difficult to intubate
 Difficult to perform cricothyrotomy
Difficult to Bag (MOANS)
 Mask Seal
 Obesity or Obstruction
 Age > 55
 No Teeth
 Stiff
 MOANS
Mask Seal
 Small Hands
 Wrong Mask Size
 Oddly Shaped Face
 Bushy Beard
 Blood/Vomit
 Facial Trauma
 MOANS
Obesity or Obstruction
 Obesity
 Heavy chest
 Abdominal contents inhibit movement of the
diaphragm
 Increased supraglottic airway resistance
 Billowing cheeks
 Difficult mask seal
 Quicker desaturation
 MOANS
Obesity or Obstruction
 3rd Trimester Pregnancy
 Increased body mass
 Quick desaturation
 Increased Mallampati Score
 Gravid uterus inhibits movement of the
diaphragm
 MOANS
Obesity or Obstruction
 Obstructions
 Foreign Body
 Angioedema
 Abscesses
 Epiglottitis
 Cancer
 Traumatic Disruption/Hematoma/Burns
 MOANS
Age > 55
 Associated with BVM difficulty, possibly
due to loss of tone in the upper airway
 MOANS
No Teeth
 Face tends to “cave in”
 Consider leaving dentures in for BVM
and remove for intubation
 MOANS
Stiff
 Refers to Poor Compliance
 Reactive Airway Disease
 COPD
 Pulmonary Edema/Advance Pneumonia
 History of Snoring/Sleep Apnea
 Also predicts a higher Mallampati score
Difficult Laryngoscopy & Intubation

 LEMONS
 Look Externally
 Evaluate 3-3-2
 Mallampati Score
 Obstruction
 Neck Mobility
 Scene and Situation
 LEMONS
LOOK Externally
 Beards or facial hair
 Short, fat neck
 Morbidly obese patients
 Facial or neck trauma
 Broken teeth (can lacerate balloons)
 Dentures (should be removed)
 Large teeth
 Protruding tongue
 A narrow or abnormally shaped face
 LEMONS
EVALUATE 3-3-2
 Bottom of Jaw/Chin to Neck >
3 fingers
 Jaw/Palate > 3 fingers wide
 Mouth opens > 2 fingers wide

Any single indicator has poor specificity

 LEMONS
EVALUATE 3-3-2
 Mouth Opens at least 3 finger widths.

 Three finger widths thyromental distance.

 Two finger widths mandibulohyoid

distance.
 LEMONS
EVALUATE 3-3-2
 Will patients mouth open wide
enough to accommodate 3 fingers?
 Will 3 fingers fit between the mentum
and hyoid bone?
 Will 2 fingers fit between the hyoid
and thyroid notch?
 If not, expect a difficult intubation
 LEMONS
Mouth opens at least 3 fingers width?
 LEMONS
Thyromental Distance
 Distance from the mentum to the thyroid
notch.
 Ideally done with the neck fully extended.
Can be done in-line
 Helps determine how readily the laryngeal
axis will fall in line with the pharyngeal
axis.
 LEMONS
Thyromental Distance
 If the thyromental distance is
short, <3 finger widths, the
laryngeal axis makes a more
acute angle with the
pharyngeal axis and it will be
difficult to achieve alignment.
 Less space to displace the
tongue.
 LEMONS
Thyromental Distance-3 fingers?
 LEMONS
Mandibulohyoid Distance- 2 fingers?
 Measured from the
mentum to the top of
the hyoid bone.
 The epiglottis arises
from the thyroid and
remains dorsal to the
hyoid bone.
 Therefore, the position
of the hyoid bone
marks the entrance to
the larynx.
 LEMONS
Mandibulohyoid Distance
 LEMONS
Mandibulohyoid Distance
 When the position of the hyoid bone is
caudal or relatively caudal, a large portion
of the tongue is situated in the
hypopharynx instead of the mouth.
 During laryngoscopy, this large
hypopharyngeal tongue mass further
compromises the compliance needed for
its displacement
 LEMONS
Mandibulohyoid Distance
 Patients who have a
longer mandibulohyoid
distance, greater then 2
finger widths, tend to
be more difficult to
intubate.

 A more caudal hyoid

bone thus indicates a
relatively caudal larynx.
 LEMONS
Upper & Lower Face
 Measure the size of the upper face as
compared to the lower face.
 Should be roughly the same.
 If the lower face is longer than the upper
face then you should anticipate some
degree of difficulty lining up the
structures.
 LEMONS
Upper and lower face equal?
 LEMONS
Upper and lower face equal?
 LEMONS
Mallampati Score
 LEMONS
Mallampati Score
 Have patient sit up, and stick out
tongue without phonating
 May be unable to properly assess this in
an emergent field situation
 Modified version is to use a
laryngoscope blade like a tongue blade
to visualize the oropharynx – (not as
sensitive or specific)
 LEMONS
Mallampati Classification
 Relates to tongue size to pharyngeal size.
 Performed with patient in a sitting
position, head neutral, mouth open wide
and tongue protruding to the maximum.
 The Subsequent Classification is assigned
based upon the pharyngeal structures
visible.
 LEMONS
Mallampati Classification
 Class I: Visualization of the soft palate,
fauces, uvula, and anterior & posterior
pillars
 LEMONS
Mallampati Classification
 Class II: Visualization of the Soft palate,
fauces and uvula.
 LEMONS
Mallampati Classification
 Grade III: Visualization of the soft palate
and the base of the uvula.
 LEMONS
Mallampati Classification
 Grade IV: The soft palate is not visible at
all.
LEMONS
 LEMONS
Mallampati Classification
 LEMONS
Obstruction
 Laryngoscopy or intubation
may be more difficult in the
presence of an obstruction
 Anatomy
 Trauma
 Foreign body obstruction
 Edema (burns)
Obstructions LEMONS
Laryngoscopic View Grades
Grade 1: Full aperture visible
Grade 2: Lower part of cords visible
Grade 3: Only epiglottis visible
Grade 4: Epiglottis not visible
Obstructions LEMONS
Laryngoscopic View Grades
Graded in order from the best view to
worst.
 Grade 1: Visualization of the entire
laryngeal apeture
Obstructions LEMONS
Laryngoscopic View Grades
 Grade 2: Visualization of just the posterior
portion of the laryngeal aperture.

 Grade 3: Visualization of only the

epiglottis

 Grade 4: Visualization of the soft palate

only.
Obstructions LEMONS
Laryngoscopic View Grades
 A severe grade III or IV view with failed
endotracheal intubation occurs in 0.05-
0.35% of patients
 LEMONS
Cormack & Lehane Grading

Grade I = 
success & ease
10-30%
of intubation

<5% <1%

% listed = incidence
 LEMONS
Neck Mobility
 Ideally the neck should be able to
extend back approximately 35°
 Problems:
 Cervical Spine Immobilization
 Ankylosing Spondylitis
 Rheumatoid Arthritis
 Halo fixation
 LEMONS
Scene and Situation (SEE)
 Scene safety
 Environment
 Do you have a reasonable chance to get the
tube?
 Space, positioning, access
 Egress
 Will you be able to ventilate during egress?
 A respiratory rate of 4 is better than a rate of
0!
 Enough meds for a long extrication?
 DOA
Difficult Cricothyrotomy
 DOA
 Disruption or Distortion
 Obstruction
 Access Problems

 If you can’t bag and can’t cric, they’re

DOA
 DOA
Disruption / Distortion
 Distortion
 Surgeries
 Radiation Therapy
 Scarring
 Burns
 DOA
Disruption / Distortion
 Disruption
 Hanging
 Crush Injuries
 Penetrating Trauma
 Other Soft Tissue Trauma
 Burns
 Laceration
 DOA
Obstructions
 Hematoma
 Abscess
 Tumor
 Tumors can also create distortions & extra
bleeding
 DOA
Access Issues
 Obesity
 Halo
 Short neck
 SC Emphysema
 Bushy beard
 Flexion deformity of the spine
“BURP” – a.k.a.
“External Laryngeal Manipulation”
 Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
 90% of the time the
best view will be
obtained by pressing
over the thyroid
cartilage

Differs from the Sellick Maneuver

To Summarize
 Airway assessment is a critical part of
the RSI process
 The difficult airway assessment must be
performed prior to ALL RSI attempts.
 While this criteria helps identify difficult
airways, it does not guarantee an easy
intubation—Be Prepared!